National Perinatal Epidemiology Centre

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The National Perinatal Epidemiology Centre is based in Cork University Maternity Hospital. The overall objective of the Centre is to collaborate with Irish maternity services to translate clinical audit data and epidemiological evidence into improved maternity care for families in Ireland.

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At what price? A cost-effectiveness analysis comparing trial of labour after previous caesarean versus elective repeat caesarean delivery
(Public Library of Science, 2013-03-06) Fawsitt, Christopher G.; Bourke, Jane; Greene, Richard A.; Everard, Claire M.; Murphy, Aileen; Lutomski, Jennifer E.; National Perinatal Epidemiology Centre, College of Medicine and Health, University College Cork
Background: Elective repeat caesarean delivery (ERCD) rates have been increasing worldwide, thus prompting obstetric discourse on the risks and benefits for the mother and infant. Yet, these increasing rates also have major economic implications for the health care system. Given the dearth of information on the cost-effectiveness related to mode of delivery, the aim of this paper was to perform an economic evaluation on the costs and short-term maternal health consequences associated with a trial of labour after one previous caesarean delivery compared with ERCD for low risk women in Ireland.Methods: Using a decision analytic model, a cost-effectiveness analysis (CEA) was performed where the measure of health gain was quality-adjusted life years (QALYs) over a six-week time horizon. A review of international literature was conducted to derive representative estimates of adverse maternal health outcomes following a trial of labour after caesarean (TOLAC) and ERCD. Delivery/procedure costs derived from primary data collection and combined both "bottom-up" and "top-down" costing estimations.Results: Maternal morbidities emerged in twice as many cases in the TOLAC group than the ERCD group. However, a TOLAC was found to be the most-effective method of delivery because it was substantially less expensive than ERCD ((sic)1,835.06 versus (sic)4,039.87 per women, respectively), and QALYs were modestly higher (0.84 versus 0.70). Our findings were supported by probabilistic sensitivity analysis.Conclusions: Clinicians need to be well informed of the benefits and risks of TOLAC among low risk women. Ideally, clinician-patient discourse would address differences in length of hospital stay and postpartum recovery time. While it is premature advocate a policy of TOLAC across maternity units, the results of the study prompt further analysis and repeat iterations, encouraging future studies to synthesis previous research and new and relevant evidence under a single comprehensive decision model.
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Caesarean delivery and subsequent pregnancy interval: a systematic review and meta-analysis
Cesarean section and rate of subsequent stillbirth, miscarriage and ectopic pregnancy: a Danish register-based cohort study
(Public Library of Science, 2014-07-01) O'Neill, Sinéad M.; Agerbo, Esben; Kenny, Louise C.; Henriksen, Tine B.; Kearney, Patricia M.; Greene, Richard A.; Mortensen, Preben Bo; Khashan, Ali S.; Fisk, Nicholas M.; Health Research Board; Science Foundation Ireland; National Perinatal Epidemiology Centre, College of Medicine and Health, University College Cork
Background: With cesarean section rates increasing worldwide, clarity regarding negative effects is essential. This study aimed to investigate the rate of subsequent stillbirth, miscarriage, and ectopic pregnancy following primary cesarean section, controlling for confounding by indication. Methods and Findings: We performed a population-based cohort study using Danish national registry data linking various registers. The cohort included primiparous women with a live birth between January 1, 1982, and December 31, 2010 (n = 832,996), with follow-up until the next event (stillbirth, miscarriage, or ectopic pregnancy) or censoring by live birth, death, emigration, or study end. Cox regression models for all types of cesarean sections, sub-group analyses by type of cesarean, and competing risks analyses for the causes of stillbirth were performed. An increased rate of stillbirth (hazard ratio [HR] 1.14, 95% CI 1.01, 1.28) was found in women with primary cesarean section compared to spontaneous vaginal delivery, giving a theoretical absolute risk increase (ARI) of 0.03% for stillbirth, and a number needed to harm (NNH) of 3,333 women. Analyses by type of cesarean section showed similarly increased rates for emergency (HR 1.15, 95% CI 1.01, 1.31) and elective cesarean (HR 1.11, 95% CI 0.91, 1.35), although not statistically significant in the latter case. An increased rate of ectopic pregnancy was found among women with primary cesarean overall (HR 1.09, 95% CI 1.04, 1.15) and by type (emergency cesarean, HR 1.09, 95% CI 1.03, 1.15, and elective cesarean, HR 1.12, 95% CI 1.03, 1.21), yielding an ARI of 0.1% and a NNH of 1,000 women for ectopic pregnancy. No increased rate of miscarriage was found among women with primary cesarean, with maternally requested cesarean section associated with a decreased rate of miscarriage (HR 0.72, 95% CI 0.60, 0.85). Limitations include incomplete data on maternal body mass index, maternal smoking, fertility treatment, causes of stillbirth, and maternally requested cesarean section, as well as lack of data on antepartum/intrapartum stillbirth and gestational age for stillbirth and miscarriage. Conclusions: This study found that cesarean section is associated with a small increased rate of subsequent stillbirth and ectopic pregnancy. Underlying medical conditions, however, and confounding by indication for the primary cesarean delivery account for at least part of this increased rate. These findings will assist women and health-care providers to reach more informed decisions regarding mode of delivery.
Communication skills in Obstetrics: what can we learn from bereaved parents?
(Irish Medical Organisation, 2017-02) Nuzum, Daniel; Meaney, Sarah; O'Donoghue, Keelin
Communicating bad news in obstetrics is challenging. This study explores the impact of how bad news was communicated to parents following a diagnosis of stillbirth. Qualitative in-depth interviews were conducted with 12 mothers and 5 fathers, bereaved following stillbirth at a tertiary maternity hospital where the perinatal mortality rate is 5.2/1000. Data were analysed using Interpretative Phenomenological Analysis. How the diagnosis of stillbirth was communicated had a profound and lasting impact on parents. Dominant superordinate themes were Language used, Sensitivity and Diversionary techniques. Parents recalled in detail where and how bad news was broken and language used. Diversionary techniques created a sense of mistrust especially when parents felt information was being withheld. Bereaved parents valued privacy at the time of diagnosis of stillbirth. This study highlights the importance of language, sensitivity and environment where clinicians can learn from the experiences of bereaved parents who value open, sensitive and honest communication. The results of this study highlight the importance of patient-focused communication training for clinicians.
A cost-benefit analysis of two alternative models of maternity care in Ireland
(Springer International Publishing; Adis, 2017-08-21) Fawsitt, Christopher G.; Bourke, Jane; Murphy, Aileen; McElroy, Brendan; Lutomski, Jennifer E.; Murphy, Rosemary; Greene, Richard A.; University College Cork
Background: The Irish government has committed to expand midwifery-led care alongside consultant-led care nationally, although very little is known about the potential net benefits of this reconfiguration. Objectives: To formally compare the costs and benefits of the major models of care in Ireland, with a view to informing priority setting using the contingent valuation technique and cost-benefit analysis. Methods: A marginal payment scale willingness-to-pay question was adopted from an ex ante perspective. 450 pregnant women were invited to participate in the study. Cost estimates were collected primarily, describing the average cost of a package of care. Net benefit estimates were calculated over a 1-year cycle using a third-party payer perspective. Results: To avoid midwifery-led care, women were willing to pay €821.13 (95% CI 761.66–1150.41); to avoid consultant-led care, women were willing to pay €795.06 (95% CI 695.51–921.15). The average cost of a package of consultant- and midwifery-led care was €1,762.12 (95% CI 1496.73–2027.51) and €1018.47 (95% CI 916.61–1120.33), respectively. Midwifery-led care ranked as the best use of resources, generating a net benefit of €1491.22 (95% CI 989.35–1991.93), compared with €123.23 (95% CI −376.58 to 621.42) for consultant-led care. Conclusions: While both models of care are cost-beneficial, the decision to provide both alternatives may be constrained by resource issues. If only one alternative can be implemented then midwifery-led care should be undertaken for low-risk women, leaving consultant-led care for high-risk women. However, pursuing one alternative contradicts a key objective of government policy, which seeks to improve maternal choice. Ideally, multiple alternatives should be pursued.
Data quality in the evolving digitised health service
(University College Cork, 2021) McKernan, Joye; Greene, Richard A.; Corcoran, Paul
Background/Objective: The research undertaken for this thesis focussed on data quality in the evolving digitised health service. In Ireland we all need to have our details on an electronic healthcare record. We need to have fully integrated systems documenting our health information across our whole life. We as patients need to be central to our care and have access to our data. EHRs can change healthcare by saving money, improving communication, and reducing errors. The introduction of an EHR is a substantial change management project that needs to include all stakeholders to ensure success. It requires vision, dedication, time, and patience. The power and importance of data cannot be overemphasised; we need to analyse what is required from data, using robust standard approaches, and ensure data is of high quality so that it can be used to improve patient outcomes and improve staff working conditions. The aim of this research project was to focus on aspects of digitisation that go towards achieving a high-quality data repository. We aimed to investigate the development and use of an EHR in the Irish healthcare system with specific consideration to the elements that impact data quality. We examined the experiences of the development team, patients, staff, service culture and the data collected. Methods: We used both quantitative and qualitative methods; this mixed method approach allowed for a deeper understanding of the issues. A document analysis of the closure report of the implementation of the EHR (MN-CMS) from the national project team was supported with discussions with team members. Patients at antenatal booking visits in an Irish maternity unit were invited to participate and complete a survey with respect to digitization of their health data. The survey was divided into three distinctive sections; participant information, regarding the staff encounters on their visits and questions about the new system. To engage with staff a pre- EHR implementation survey, a post EHR implementation survey and a post-implementation EHR documentation audit was carried out. A four-step approach was required when applying a national framework to a national data set. The four steps included a literature review, using elements of a data quality framework to develop the planning of an audit tool, data quality assessment of the Major Obstetric Haemorrhage (MOH) audit dataset. The fourth step assessed the data quality using the five dimensions of quality: (1) relevance, (2) accuracy and reliability, (3) timeliness and punctuality, (4) coherence and comparability, and (5) accessibility and clarity. To explore data quality in an EHR two phases were used; initially we examined the data from year 1 (2018); following analysis of the data set we found data quality issues. We then enacted an intervention and assessed the effect of a new data quality process. The intervention was to introduce a data quality resource to assess the datapoints within 1-2 days after documentation of the care by the healthcare professional. We assessed clinical data extracted from the MN-CMS national database for missing data and then examined the significance of the data issues. An ethnographic study approach was used to explore service culture around shift clinical handover, the process was divided into three components: an observational study, a short staff survey and a cause-and-effect assessment. Results: This project showed that several factors, need to be explored to fully understand data quality in healthcare. There is a growing need for high quality clinical ‘Big Data’ to measure, enhance and evaluate healthcare; clinical data systems need to be producing high quality complete and accurate data for primary and secondary use. Patients want to have access to their records and want to engage with healthcare professionals in their care. This engagement will lead to patients having more control over their health outcomes. EHRs are now becoming more and more widespread globally; in Ireland the Maternal & Newborn Clinical Management System (MN-CMS) has been implemented for four maternity units and is a pathfinder EHR project. It is a clinically led, patient centred EHR. Staff engagement is required for the implementation phase; they are a vital component to ensure a successful implementation. Staff may require additional training to ensure their documentation positively impacts data quality. There is a requirement to standardise terminology in relation to data quality and use data quality frameworks to assess the dimension of data quality. It is meaningful and useful to apply national data quality frameworks to data sets to investigate where improvements may be made. Capturing and ensuring quality data from an EHR takes time and resources; the data needs to be examined for accuracy and completeness. Resources in the form of staff are required to achieve this impact on data quality. They can improve data directly and more importantly they can engage with staff regarding their documentation, identify need for further training, technical solution changes and indeed review of data points and the value of recording them. Following the implementation of an EHR, workflows and practices might not change when they should have; it is important to explore why these changes may not occur and address the issues to identify the barriers and allow enablers to achieve appropriate change, engaging with staff in the process. Conclusion: This project aimed to explore the impacts of digitizing healthcare documentation on the quality of that data, examining the impact through patients, staff, and processes. This thesis has shown a need to move towards standardised terminology and methodologies to achieve these goals and the projects involved took a practical solutions approach. We have shown the importance of staff members and their role in the success of the project implementation. We have highlighted the importance of the use of frameworks to robustly assess data quality. There is growing literature regarding EHRs and data quality with the rapid expansion in digitization of healthcare data. This thesis adds to that literature, but significantly more work is needed in the areas of standardisation of data quality frameworks, the importance of staff in data quality, and co-designed patient portals.
The development of the Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS): a large-scale data sharing initiative
(Public Library of Science, 2013) Lutomski, Jennifer E.; Baars, Maria A. E.; Schalk, Bianca W. M.; Boter, Han; Buurman, Bianca M.; den Elzen, Wendy P. J.; Jansen, Aaltje P. D.; Kempen, Gertrudis I. J. M.; Steunenberg, Bas; Steyerberg, Ewout W.; Rikkert, Marcel G. M. Olde; Melis, René J. F.; ZonMw
Introduction: In 2008, the Ministry of Health, Welfare and Sport commissioned the National Care for the Elderly Programme. While numerous research projects in older persons' health care were to be conducted under this national agenda, the Programme further advocated the development of The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS) which would be integrated into all funded research protocols. In this context, we describe TOPICS data sharing initiative (www.topics-mds.eu). Materials and Methods: A working group drafted TOPICS-MDS prototype, which was subsequently approved by a multidisciplinary panel. Using instruments validated for older populations, information was collected on demographics, morbidity, quality of life, functional limitations, mental health, social functioning and health service utilisation. For informal caregivers, information was collected on demographics, hours of informal care and quality of life (including subjective care-related burden). Results: Between 2010 and 2013, a total of 41 research projects contributed data to TOPICS-MDS, resulting in preliminary data available for 32,310 older persons and 3,940 informal caregivers. The majority of studies sampled were from primary care settings and inclusion criteria differed across studies. Discussion: TOPICS-MDS is a public data repository which contains essential data to better understand health challenges experienced by older persons and informal caregivers. Such findings are relevant for countries where increasing health-related expenditure has necessitated the evaluation of contemporary health care delivery. Although open sharing of data can be difficult to achieve in practice, proactively addressing issues of data protection, conflicting data analysis requests and funding limitations during TOPICS-MDS developmental phase has fostered a data sharing culture. To date, TOPICS-MDS has been successfully incorporated into 41 research projects, thus supporting the feasibility of constructing a large (>30,000 observations), standardised dataset pooled from various study protocols with different sampling frameworks. This unique implementation strategy improves efficiency and facilitates individual-level data meta-analysis.
Discharge age and weight for very preterm infants in six countries: 2012-2020
(Karger International, 2023-01) Edwards, Erika M.; Greenberg, Lucy T.; Horbar, Jeffrey D.; Gagliardi, Luigi; Adams, Mark; Berger, Angelika; Leitao, Sara; Luyt, Karen; Ehret, Danielle E. Y.; Rogowski, Jeannette A.
Postmenstrual age for surviving infants without congenital anomalies born at 24-29 weeks' gestational age from 2005 to 2018 in the USA increased 8 days, discharge weight increased 316 grams, and median discharge weight z-score increased 0.19 standard units. We asked whether increases were observed in other countries. We evaluated postmenstrual age, weight, and weight z-score at discharge of surviving infants without congenital anomalies born at 24-29 weeks' gestational age admitted to Vermont Oxford Network member hospitals in Austria, Ireland, Italy, Switzerland, the UK, and the USA from 2012 to 2020. After adjustment, the median postmenstrual age at discharge increased significantly in Austria (3.6 days, 99% CI [1.0, 6.3]), Italy (4.0 days [2.3, 5.6]), and the USA (5.4 days [5.0, 5.8]). Median discharge weight increased significantly in Austria (181 grams, 99% CI [95, 267]), Ireland (234 [143, 325]), Italy (133 [83, 182]), and the USA (207 [194, 220]). Median discharge weight z-score increased in Ireland (0.24 standard units, 99% CI [0.12, 0.36]) and the USA (0.15 [0.13, 0.16]). Discharge on human milk increased in Italy, Switzerland, and the UK, while going home on cardiorespiratory monitors decreased in Austria, Ireland, and USA and going home on oxygen decreased in Ireland. In this international cohort of neonatal intensive care units, postmenstrual discharge age and weight increased in some, but not all, countries. Processes of care at discharge did not change in conjunction with age and weight increases.
Does membrane sweep work? Assessing obstetric outcomes and patient perception of cervical membrane sweeping at term in an Irish obstetric population: a prospective multi-centre cohort study
(Springer Nature Switzerland AG, 2020-02-05) Ugezu, C. H.; Corcoran, Paul; Dunn E. A.; Burke C.
Background: Cervical membrane sweep is a mechanical method of cervical ripening at term gestation with the aim of avoiding prolonged pregnancy and reducing the need for labour induction for this indication. There is no published data on obstetric outcomes following membrane sweep in an Irish obstetric population or any studies on patient perception/recommendation of membrane sweep in the international literature. Aims: This study is aimed at determining if cervical membrane sweep at term has an effect on duration of pregnancy and delivery outcome in an Irish population. Postnatally, patient perception of the experience of membrane sweep was evaluated as well as their recommendation of the procedure for other women. Methods: A prospective multi-centre cohort study of women who had cervical membrane sweep at term was carried out which assesses labour and delivery outcomes as well as patient perceptions in women undergoing membrane sweep. Results: Spontaneous labour occurred in 79% of women following membrane sweep. A quarter of nulliparae (25%) and 18% of multipara had labour induction despite membrane sweep. Three quarters of both nulliparae (73%) and multipara (76%) delivered within 7 days of membrane sweep. In the presence of a Bishop score greater than six, the rate of spontaneous labour was 97% in our patient cohort. Nine in ten women (91%) had previously heard of cervical membrane sweep. Two in three women (65%) thought that membrane sweep helped them to labour, and over 80% would recommend it to other pregnant women despite 63% of women reporting moderate discomfort with the procedure. Conclusions: Cervical membrane sweep is associated with spontaneous onset of labour within 7 days in the majority of patients, more so in the presence of higher Bishop score and better quality sweep. It has a high level of acceptability among patients and is highly recommended by them to other patients. The need for more than one membrane sweep is associated with less likelihood of spontaneous onset of labour.
Examining the construct and known-group validity of a composite endpoint for The Older Persons and Informal Caregivers Survey Minimum Data Set (TOPICS-MDS); A large-scale data sharing initiative
(Public Library of Science, 2017-03-15) Hofman, Cynthia S.; Lutomski, Jennifer E.; Boter, Han; Buurman, Bianca M.; de Craen, Anton J. M.; Donders, Rogier; Olde Rikkert, Marcel G. M.; Makai, Peter; Melis, René J. F.; TOPICS-MDS research consortium; ZonMw
Background: Preference-weighted multi-faceted endpoints have the potential to facilitate comparative effectiveness research that incorporates patient preferences. The Older Persons and Informal Caregivers Survey—Composite endpoint (TOPICS-CEP) is potentially a valuable outcome measure for evaluating interventions in geriatric care as it combines multiple outcomes relevant to older persons in a single metric. The objective of this study was to validate TOPICS-CEP across different study settings (general population, primary care and hospital). Methods: Data were extracted from TOPICS Minimum Dataset (MDS), a pooled public-access national database with information on older persons throughout the Netherlands. Data of 17,603 older persons were used. Meta-correlations were performed between TOPICS-CEP indexed scores, EuroQol5-D utility scores and Cantril’s ladder life satisfaction scores. Mixed linear regression analyses were performed to compare TOPICS-CEP indexed scores between known groups, e.g. persons with versus without depression. Results: In the complete sample and when stratified by study setting TOPICS-CEP and Cantril’s ladder were moderately correlated, whereas TOPICS-CEP and EQ-5D were highly correlated. Higher mean TOPICS-CEP scores were found in persons who were: married, lived independently and had an education at university level. Moreover, higher mean TOPICS-CEP scores were found in persons without dementia, depression, and dizziness with falls, respectively. Similar results were found when stratified by subgroup. Conclusion: This study supports that TOPICS-CEP is a robust measure which can potentially be used in broad settings to identify the effect of intervention or of prevention in elderly care.
Experience of miscarriage: an interpretative phenomenological analysis
(BMJ Publishing Group Ltd, 2017-03-01) Meaney, Sarah; Corcoran, Paul; Spillane, Niamh; O'Donoghue, Keelin
Objective: The objective of the study was to explore the experiences of those who have experienced miscarriage, focusing on men's and women's accounts of miscarriage. Design: This was a qualitative study using a phenomenological framework. Following in-depth semistructured interviews, analysis was undertaken in order to identify superordinate themes relating to their experience of miscarriage. Setting: A large tertiary-level maternity hospital in Ireland. Participants: A purposive sample of 16 participants, comprising 10 women and 6 men, was recruited. Results: 6 superordinate themes in relation to the participant's experience of miscarriage were identified: (1) acknowledgement of miscarriage as a valid loss; (2) misperceptions of miscarriage; (3) the hospital environment, management of miscarriage; (4) support and coping; (5) reproductive history; and (6) implications for future pregnancies. Conclusions: One of the key findings illustrates a need for increased awareness in relation to miscarriage. The study also indicates that the experience of miscarriage has a considerable impact on men and women. This study highlights that a thorough investigation of the underlying causes of miscarriage and continuity of care in subsequent pregnancies are priorities for those who experience miscarriage. Consideration should be given to the manner in which women who have not experienced recurrent miscarriage but have other potential risk factors for miscarriage could be followed up in clinical practice.
An exploration of miscarriage in the Republic of Ireland: incidence, management, risk factors, interventions, and populations’ knowledge
(University College Cork, 2019-08) San Lázaro Campillo, Indra; O'Donoghue, Keelin; Meaney, Sarah
Background: Miscarriage is one of the most common complications in early pregnancy. It is estimated that approximately one out of five women will have a miscarriage throughout their reproductive lives. Despite the high prevalence of miscarriage and the biopsychological burden associated with experiencing miscarriage, there are several gaps in the literature. For example, there is a lack of standardisation of definitions and types of miscarriage worldwide. This high heterogeneity in cut-offs for defining miscarriage is limiting international comparisons of the evidence available. This is distorting the recording of data related to miscarriage in national and international health databases. Furthermore, little is known about the trends of hospital admissions for miscarriage and the non-fatal complications associated with it. In fact, there is no sufficient evidence of the validity of diagnosis of miscarriage in routinely collected health databases. In addition, although approximately 50% of miscarriages are linked to chromosomal abnormalities, the underlying causes of miscarriage are still unclear for the remainer. Therefore, it is imperative to understand and identify causes and risk factors of unexplained miscarriage in order to develop effective treatments and promote healthy behaviours among the population. The most well-established risk factors for miscarriage are advanced maternal age, previous pregnancy loss and parity. However, there is a need to identify risk factors in order to be able to prevent the likelihood of experiencing miscarriage. It is accepted that women who experience miscarriage suffer from psychological morbidity after the loss and in subsequent pregnancies. Nevertheless, further research is needed in order to obtain robust evidence on what specific group of women are more susceptible to develop psychological morbidity after miscarriage, what are the psychological and emotional changes during pregnancy after a miscarriage, and what are the effective non-pharmacological interventions to improve psychological wellbeing as well as future pregnancy outcome. Outline and aims: In this thesis, I explored several dimensions surrounding the event of miscarriage. To do that, I firstly reviewed the published evidence to date about miscarriage in order to find gaps in the literature. This thesis encompassed a total of six research studies to contribute to the existing body of knowledge about miscarriage. The main objective of the first study was to determine national trends in incidence and management of inpatient admissions for early miscarriage in the Republic of Ireland. After this study, it was essential to validate the diagnosis of miscarriage in the national health system used to obtain these trends. Consequently, the aim of the second study was to compare agreement for the diagnosis of miscarriage between three types of routinely collected hospital-based health records. This thesis includes three research studies that explored several gaps in the literature about pregnant women with a history of miscarriage. The first study explored the risk factors associated with miscarriage among women attending an early pregnancy assessment unit (EPAU). The second study aimed to determine barriers and facilitators when designing large-scale longitudinal studies; and the third study was a systematic review, which aimed to identify randomised controlled trials that assessed the effect of interventions to reduce stress, anxiety and depression in pregnant women with a history of miscarriage. Finally, this thesis includes a cross-sectional study that was designed to assess university student’s knowledge of basic reproductive health information about miscarriage. Findings and clinical implications: This thesis provides additional evidence to the growing body of work focusing on miscarriage. This thesis highlights the need for unifying inpatient and outpatient data in order to estimate the total burden of miscarriage at a national level. Furthermore, it is crucial to standardise the diagnosis of the type of miscarriage at a national level. The results presented in this thesis also emphasise the misunderstanding of causes, signs and symptoms of miscarriage, which shows it is essential to inform the public about miscarriage in general, as well as its treatments and the scientific evidence available to date. In addition, reproductive health information about miscarriage should be disseminated to a younger stratum of the population, who are at early stages in their reproductive life. Indeed, this would enable better informed decision-making about their reproductive behaviour and lifestyle by helping them to be aware of risk factors for miscarriage, identifying signs and symptoms of miscarriage and learning what to expect when experiencing a miscarriage. Moreover, providing reproductive health information about miscarriage will help the population to be aware of when and where seek for help. In this thesis, I suggest University settings as the ideal scenario to reach and promote reproductive health information about miscarriage in this targeted group. Efforts to satisfy the population’s needs on reproductive health and pregnancy loss should be made by healthcare professionals and researchers, and should also include public health advocates and policymakers. As a result of the findings from this thesis, I suggest further research in the area of miscarriage, and I outline a number of recommendations in relation to clinical practice and public policy. It is essential to obtain robust evidence on the association of poor mental health and adverse pregnancy outcomes that may lead to targeted interventions for women who are at higher risk of developing stress or mental disorder before, during and after pregnancy. The need for targeted interventions to reduce stress and increase mental wellbeing among pregnant women with a history of miscarriage is also warranted. An effort should be made to design and implement high quality, appropriately powered, RCTs that can provide reliable and non-biased evidence on preventable risk factors and effective psychological and behavioural interventions that may improve outcomes in future pregnancies. To achieve this goal, research funders need to acknowledge the burden of miscarriage at national and international level and support well-designed and large-scale RCTs. Funding RCTs in this area will lead to increase the understanding of potential interventions that might improve women´s psychological wellbeing after pregnancy loss.
An exploration of women's experience of taking part in a randomized controlled trial of a diagnostic test during pregnancy: A qualitative study
(Blackwell Publishing Ltd, 2019-10-02) Hayes-Ryan, Deirdre; Meaney, Sarah; Nolan, Caroline; O'Donoghue, Keelin
Objective: To explore pregnant women's views of participation in a clinical research trial while pregnant. Design: Prospective nested qualitative cohort study embedded within a national, multi‐site randomized controlled trial of a diagnostic test for preeclampsia: Placental Growth Factor. One‐to‐one in‐depth semi‐structured interviews were undertaken with 19 women who had recently participated in the trial at a single recruiting site. The interviews were conducted in private, recorded digitally and transcribed verbatim. Setting: Single tertiary maternity hospital currently recruiting eligible women onto an on‐going randomized controlled trial (NCT 02881073). Participants: Women who had participated in the PARROT Ireland randomized controlled trial during their recent pregnancy. Methods: Thematic analysis was utilized. Each line of the transcribed interviews was coded into a category by two researchers. The resultant categories were reviewed, and those with similarities were pooled allowing the development of themes. Main Outcome Measures: Women's opinions and experience of participation in a randomized controlled trial of an interventional diagnostic test during their pregnancy. Results: Four major themes were identified as follows: (a) Understanding of preeclampsia, (b) Motivators for clinical trial participation, (c) Barriers to decision making and (d) Influence of PARROT Ireland on pregnancy experience. Conclusions:Women are generally interested and positively inclined to participate in research during pregnancy. The potential of risk is an important consideration for eligible pregnant woman. Information and support by both researchers and clinicians are paramount in aiding women's understanding of a research trial.
Factors affecting third‐stage management and postpartum hemorrhage in planned midwife‐led home and birth center births in the United States
(John Wiley & Sons, Inc., 2020-07-29) Erickson, Elise N.; Bovbjerg, Marit L.; Cheyney, Melissa J.; Foundation for the Advancement of Midwifery; National Institutes of Health; Eunice Kennedy Shriver National Institute of Child Health and Human Development; Fulbright Association; Health Resources and Services Administration
Background: Postpartum hemorrhage (PPH) is a potential childbirth complication. Little is known about how third-stage labor is managed by midwives in the United States, including use of uterotonic medication during community birth. Access to uterotonic medication may vary based on credentials of the midwife or state regulations governing midwifery. Methods: Using data from the Midwives of North America 2.0 database (2004-2009), we describe the PPH incidence for women giving birth in the community, their demographic and clinical characteristics, and methods used by midwives to address PPH. We also examined PPH rates by midwifery credentials and by the presence of regulations for legal midwifery practice. Results: Of the 17 836 vaginal births, 15.9% had blood loss of over 500 mL and 3.3% had 1000 mL or greater blood loss. Midwives used pharmaceuticals to prevent or treat postpartum bleeding in 6.3% and 13.9% of births, respectively, and the rate of hospital transfer after birth was 1.4% (n = 247). In adjusted analyses, PPH was less likely when births occurred at home vs a birth center, if the midwife had a CNM/CM credential vs a CPM/LM/LDM credential, or if the woman was multiparous without a history of PPH or prior cesarean birth. PPH was more likely in states with barriers to midwifery practice compared with regulated states (OR: 1.26; 95% CI, 1.16-1.38).Conclusions: Women giving birth in the community experienced low overall incidence of PPH-related hospital transfer. However, the occurrence of PPH itself would likely be reduced with improved legal access to uterotonic medication.
Fetal medicine specialist experiences of providing a new service of termination of pregnancy for fatal fetal anomaly: a qualitative study
(John Wiley & Sons, Inc., 2020-09-15) Power, S; Meaney, Sarah; O'Donoghue, Keelin
Objective: To explore fetal medicine specialists' experiences of caring for parents following a diagnosis of fatal fetal anomaly (FFA) during the implementation of termination of pregnancy (TOP) for FFA for the first time. Design: Qualitative study. Setting: Fetal medicine units in the Republic of Ireland. Population: Ten fetal medicine specialists from five of the six fetal medicine units. Methods: nvivo 12 assisted in the thematic analysis of semi-structured in-depth face-to-face interviews. Main outcome measures: Fetal medicine specialists' experiences of prenatal diagnosis and holistic management of pregnancies complicated by FFA. Results: Four themes were identified: 'not fatal enough', 'interactions with colleagues', 'supporting pregnant women' and 'internal conflict and emotional challenges'. Fetal medicine specialists feared getting an FFA diagnosis incorrect because of media scrutiny and criminal liability associated with the TOP for FFA legislation. Challenges with the ambiguous and 'restrictive' legislation were identified that 'ostracised' severe anomalies. Teamwork was essential to facilitate opportunities for learning and peer support; however, conflict with colleagues was experienced regarding the diagnosis of FFA, the provision of feticide and palliative care to infants born alive following TOP for FFA. Participants reported challenges implementing TOP for FFA, including the absence of institutional support and 'stretched' resources. Fetal medicine specialists experienced internal conflict and a psychological burden providing TOP for FFA, but did so to 'provide full care for women'. Conclusions: Our study identified challenges regarding the suitability of the Irish legislation for TOP for FFA and its rapid introduction into clinical practice. It illustrates the importance of institutional and peer support, as well as the need for supportive management, in the provision of a new service. Tweetable abstract: The implementation of termination services for fatal fetal anomaly is complex and requires institutional support.
The general populations’ understanding of first trimester miscarriage: a cross sectional survey
(Elsevier, 2020-09-10) McCarthy, Claire M.; Meaney, Sarah; Rice, Rachel; Sheehan, Jacqueline; O'Donoghue, Keelin
Objectives: Miscarriage is a common, yet for many, devastating adverse pregnancy outcome. However, despite this the level of public knowledge on the topic is sub-optimal. We aimed to examine the general public’s knowledge of miscarriage as well as their health information seeking behaviours associated with this topic. Study Design: We commissioned a national cross-sectional telephone survey of adults in the Republic of Ireland. 967 members of the general public consented to participate to this anonymised telephone survey. Sampling procedures ensured proportionality as per national standards. We examined respondents’ definitions of miscarriage, its incidence and clinical findings, as well as the information seeking behaviours of the general population surrounding miscarriage. Results: 699 (72%) of respondents provided an estimate of miscarriage frequency, with 28% of respondents correctly estimating that miscarriage occurs in 21-30% of pregnancies, with 61% under-estimating the incidence. Men were three times more likely than women to under-estimate (aOR3.5; 95% CI 2.4-4.9), as were those without children (aOR 1.7; 95% CI 1.2-2.6), or those living in urban areas (aOR 1.6; 95% CI 1.0-2.4. One third of respondents (33%) believed that the risk of miscarriage was higher following only one miscarriage. While 83% of respondents knew someone who had experienced a miscarriage, just over one third had discussed the topic of miscarriage with a family member/friend. Conclusions: The general populations’ knowledge of miscarriage, its incidence and associated factors is concerning, as are their health information seeking behaviours. Improving the level of knowledge of the general public could be achieved by adopting the topic into existing public health and education strategies. This will allow those experiencing miscarriage to frame their experience and expectations.
The impact of stillbirth on bereaved parents: A qualitative study
(Public Library of Science, 2018) Nuzum, Daniel; Meaney, Sarah; O'Donoghue, Keelin
Purpose: To explore the lived experiences and personal impact of stillbirth on bereaved parents. Methods: Semi-structured in-depth interviews analysed by Interpretative Phenomenological Analysis (IPA) on a purposive sample of parents of twelve babies born following fetal death at a tertiary university maternity hospital in Ireland with a birth rate of c8,500 per annum and a stillbirth rate of 4.6/1000. Results: Stillbirth had a profound and enduring impact on bereaved parents. Four superordinate themes relating to the human impact of stillbirth emerged from the data: maintaining hope, importance of the personhood of the baby, protective care and relationships (personal and professional). Bereaved parents recalled in vivid detail their experiences of care following diagnosis of stillbirth and their subsequent care. The time between diagnosis of a life-limiting anomaly or stillbirth and delivery is highlighted as important for parents as they find meaning in their loss. Conclusions: The impact of stillbirth on bereaved parents is immense and how parents are cared for is recalled in precise detail as they revisit their experience. Building on existing literature, these data bring to light the depth of personal experience and impact of stillbirth for parents and provides medical professionals with valuable insights to inform their care of bereaved parents and the importance of clear and sensitive communication.
Influence of cost on contraceptive choices amongst university students
(Irish Medical Organisation, 2021) McConnell, Roisin; Meaney, Sarah; O'Donoghue, Keelin
Introduction: Cost remains a major barrier in accessing effective contraception especially long-acting reversible contraception. This study sought to assess the current contraception choices amongst university students including the influence of cost on choices. Methods: A cross-sectional study of Irish university students at University College Cork was undertaken. The online survey examined current contraception use, justifications for this choice of contraception and the effect that hypothetical provision of free contraception would have on their choices. Results: A total of 1,840 sexually active students completed the online survey. Condoms were used by 1,020 students (55.4%), the combined pill was used by 729 (39.6%) and ‘coitus interruptus’ was used by 169 students (9.1%). Statistically males were more likely to spend under €50 annually (47.6%, n=182 of 382, p<0.001) and female students were more likely to spend over €100 on contraception (41.2%, n=470 of 1,141, p<0.001).By removing cost, 394 (34.3%) sexually active women would definitely change contraception, with another 250 women (21.8%) considering changing. Discussion: Students often rely on unreliable or user-dependent methods of contraception. Our study has demonstrated that cost influences contraceptive choice with nearly half of the women surveyed stating they would change contraception if cost was removed.
Irish inquiry reports relating to perinatal deaths and pregnancy loss services
(Irish Medical Organisation, 2020-02) Helps, Änne; Leitao, Sara; O'Byrne, L.; Greene, Richard A.; O'Donoghue, Keelin
Aims: External inquiries are carried out following specific adverse events in healthcare, many in maternity care; to identify issues and make recommendations to improve standards of care. Methods: Ten publically-available national inquiry reports published between 2005-2018 relating to pregnancy loss services, were reviewed by 2 clinicians, separately, examining the content and recommendations from each report. Results: A total of 258 recommendations were made in 9 reports (90%). Five inquiries (50%) clearly stated that affected families were involved and four (40%) involved affected clinical staff. In 9 reports (90%) recommendations included: increase workforce staffing and/or training, strengthen clinical governance, enhance adverse incident management and comprehensive data collection e.g. maternity outcomes. Only two inquiry reports (20%) stated that feedback was sought from key stakeholders prior to publication. Conclusion: A collaborative and standardised inquiry process involving and supporting all persons affected as well as key stakeholders would ensure that all relevant issues are identified, recommendations are implemented and essential lessons are learned.
The maternal and perinatal implications of hypertensive disorders of pregnancy in a multiple pregnancy cohort
(John Wiley & Sons, Inc., 2019-11-23) Hayes-Ryan, Deirdre; Meaney, Sarah; Hodnett, Aoibhin; Geisler, Minna; O'Donoghue, Keelin
Introduction: Hypertensive Disorders of Pregnancy are common and may result in increased maternal and neonatal morbidity and mortality. Multiple pregnancies confer an increased risk of development of a hypertensive disorder of pregnancy. The purpose of this study was to examine a large cohort of women delivering a multiple pregnancy in a single large tertiary unit, and to evaluate the implications of hypertensive disorders of pregnancy on both maternal and perinatal outcomes. Material and methods: Retrospective study of all twin pregnancies delivered at Cork University Maternity Hospital, Ireland over a 9‐year period (2009–2017). The twin pregnancies were divided according to the presence or absence of hypertensive disorder of pregnancy and the two groups compared. Results: Maternal age >40 years, nulliparity, conception through use of a donor oocyte, and presence of obstetric cholestasis are all risk factors for the development of Hypertensive Disorders of Pregnancy in women with a multiple pregnancy. When a hypertensive disorder complicates a twin pregnancy, it increases the incidence of iatrogenic late prematurity & neonatal hypoglycaemia. Conclusions: This study is informative for clinicians caring for women with a multiple pregnancy with its relevant data on perinatal outcomes following a diagnosis of hypertensive disorder in pregnancy.

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